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APPLICATION FOR PERMIT 00 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> EXP RES 1 YEAR FR M DATE ED <br /> (Complete in Triplicate) <br /> ` Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$52 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address J <br /> Q SQA City 5���_ Lot Size/Acreage 20 "4G� <br /> � Q <br /> Owners Name Cdr`l 6 ►-�- p� Address _I f a � � —1-" -f-- Phone <br /> 5 i�CI�G(' I-- 4�_ O aj Phone <br /> Contractor�L�Lr Address License No. <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well L1 <br /> PUMP INSTALLATION SYSTEM REPAIR L1OTHER ❑ Monitoring Well C7 <br /> r ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy (Type of Casing i Specifications <br /> I"I Public [A Other I-1 Delta Depth of Grout Seal Type of Grout T - <br /> jI i Irritation _ .Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump 5 U. H.P. 3-- State Work Done <br /> Welt Destruction ❑ Well Diameter Sealing Material Depth <br /> Depth Filler Material Is Depth r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.I, \ <br /> Installation will serve: Residence} Commercial— Other <br /> Number of living units: Number of bedrooms <br /> t <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines : Total langth76ize r <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> i SUMPS Ul Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 ' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County j f? <br /> Home owner or licensed agent's signature certifies the following: "i certify that in the performance of the work for which this permit is issued, I shall not <br /> i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California," ' <br /> k The applicant/ t call for all required inspection-s. Complete dra "ng on r rse side. = <br /> Signed — - itie:--_. . Al Date: <br /> f; EMT USE ONLY <br /> Application Accepted by Date �_1 v Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: , ✓ , S ����� !� ' `W� f <br /> Applicant - Return all copies to. Sen Joaquin County Public Health SS jji �6 <br /> i Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> GEE <br /> INFO AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY PATE PERMIT'N0. <br /> ' . EH 13-24IREV.linsf 13�- tti l3 ,n� S3�r3� ti-a�-�� 41 <br /> t�= Ja2. <br /> EH 74-Ze <br /> 1 <br />